SES/CDP Application Intake Information

Applicant Information
1. Job title in announcement 2. Announcement Number

3. Name
Last name First name Middle name

4. Mailing Address (Use Standard State Postal Codes (abbreviations). If outside the United States of America, and you
do not have to have a military address, type or print “OV” in the State field, leaving the ZIP code field blank.)
Street City State ZIP Code Country

5. Phone numbers (include area code if within 6. Email address (if available)
the United States of America)
Daytime Evening

Education
7. Mark highest level completed
Some HS HS/GED Associate Bachelor Master Doctoral
General
8. Are you a U.S. Citizen? Yes No

9. Are you eligible for reinstatement in the career SES? If yes,

Yes No
attach copy of Notification of Personnel Action (SF 50) as proof.

10. Were you ever a Federal civilian employee?

Yes No
If yes, fill in the information below showing the highest civilian grade held.
Series Grade From (mm/yyyy) To (mm/yyyy)

Other Qualifications
Job related education, publications, memberships in professional/honor societies, leadership activities, public speaking,
etc. - give dates, but do not send documents or certificates.

Privacy Act Notice

This form solicits personal information from individuals applying for Senior Executive Service (SES) positions in the Internal Revenue
Service or its SES Candidate Development Program. The authority to collect this information is 5 U.S.C. 301, 3131, 3301 and 3302.
We need the information requested on this form to evaluate your qualifications. We may disclose this information to the Office of
Personnel Management for review and certification of your Executive Core Qualifications. We may disclose this information to a former
employer to confirm SES reinstatement eligibility, tenure of employment, civil service status, or length of service. We may also disclose
this information to the Office of Special Counsel or the Equal Employment Opportunity Commission for adjudicating a complaint. You
are not required to provide this information, however, failure to furnish the requested information may delay or prevent consideration of
the application; providing false information may subject you to penalties.

Form 13896 (6-2007) Catalog Number 50261V Department of the Treasury - Internal Revenue Service